Previous studies of geriatric assessment have demonstrated varying degrees of effectiveness, but the structure of some of the more effective assessment programs have been difficult to duplicate in the community. Reimbursement has been limited for inpatient assessment units; consultation on geriatric inpatients is hindered by a declining length of acute hospital stay; and the efficacy of outpatient assessment remains uncertain. The proposed study tests the effectiveness of an assessment intervention that can more easily be duplicated in the community. We propose an intervention designed to enhance function and decrease mortality among at-risk elderly patients recently discharged from the hospital. The intervention will have 3 components: a post-discharge home interdisciplinary geriatric assessment; provision of individualized treatment recommendations to the patient's physician; and a system to facilitate implementation of the recommendations. In a randomized trial of this intervention, we propose to answer the following principal questions: Does this form of geriatric assessment improve patients' functional status and independence? Does it reduce hospital readmission? Does a "physician-friendly" system achieve high rates of physician adherence with assessment recommendations? Is this form of geriatric assessment a cost-effectiveness means of enhancing the independence and functional status of older persons? We will identify hospitalized older patients, about to be discharged to home, who are at risk for loss of functional independence. These patients will be randomly assigned to 2 groups. The experimental group will receive a home assessment within 3 days of hospital discharge by a gerontologic nurse practitioner working with an interdisciplinary team that includes a geriatrician, social worker, physical therapist, and occupational therapist. Recommendations from this assessment will be provided to the patient's primary physician. The control group will receive usual post- hospital care. Study outcomes will be assessed at 30, 60, 90, and 180 days after hospital discharge.